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Pledge your organ now

Pledge your organ now

Fields marked with * are mandatory.

First Name * :

Last Name * :

Father/Husband Name :

Gender * :

Blood Group :

Email * :

Address * :

City * :

Pin Code :

State * :

Witness Details

Name * :

Relationship * :

Address :

Contact Number * :

Organs/ Tissues to be pledged * :

I wish that after my death:- * :

Terms & Conditions * : I hereby unequivocally authorize the removal of my organ / organs, mentioned above from my body after my death for therapeutic purposes. I hereby confirm that I am aware of the importance of having the witness signature on the Pledge card, and I take full responsibility for its implementation I hereby confirm that all the above information is right and I choose to pledge my organs being in the sane state of mind.